“One-per-mil” Tumescent Technique for Hand Surgery

Abstract

Sir: It is generally accepted that a bloodless operative field is very important in hand and upper extremity surgery. Surgeons across the world generally use a tourniquet to achieve this condition. The use of epinephrine to attain a clear operative field was hindered by an old belief that epinephrine could cause tissue necrosis in end-artery organs.1 However, numerous studies have demonstrated that use of epinephrine in hand and finger surgery is safe.2,3 The pneumatic tourniquet has several disadvantages compared with epinephrine, including adverse tourniquet effects, limited operative time, application interference with the operative field, the relative necessity to utilize general anesthesia, and the unnecessary ischemic effect on tissue unrelated to the operative field. Previously, epinephrine use to create a bloodless operative field usually involved epinephrine concentrations ranging from 1:80,000 to 1:400,000.1,4 This technique was performed mostly in tendon, carpal tunnel, and Dupuytren contracture release.4,5 In recent years, the senior author has used “one-per-mil” tumescent solution with a significantly lower epinephrine concentration (1:1,000,000) to create a clear operative field in various procedures other than the aforementioned ones. The substantially lower epinephrine concentration in this solution successfully maintained its hemostatic effectiveness, which was expected to be safer. The novel surgical procedures performed by the senior author using this epinephrine hemostasis technique have included burn contracture release, pediatric hand cases, and flap procedures.2 Fifty milliliters of one-per-mil tumescent solution was formulated by adding diluted epinephrine (1:1,000,000 concentration) to 100 mg of lidocaine in saline solution. The solution was injected locally in the operative field. The injected volume was considered sufficient when the tissue turned pale. Most of the time, the effect showed a clear operative field, with some slight pediatric acrosyndactyly bleeding. We present a case of a 1-year-old boy with Apert hand syndrome. The operation was performed using one-per-mil tumescent solution without tourniquet application. The hand bled at skin incision, but not excessively. Light regular gauze sweeping kept the blood from obscuring the field during the procedure. Overall, the bleeding and gauze sweeping did not hinder either recognition of the anatomical structures or the surgical procedures themselves (Fig. 1).Fig. 1: Operative field of a 1-year-old boy with Apert hand and foot syndrome. (Above) The operative after skin incision. (Below) The operative field after skin incision and deeper dissection. The bloodstain on the dorsal surface of the hand and on the linen background shows that bleeding did occur, but it was easily controlled with gauze sweeping. The surgeon could recognize anatomical structures and perform the operation precisely.One-per-mil tumescent solution created a totally bloodless operative field, the clarity of which was similar to that of operative fields attained by pneumatic tourniquet application. According to the senior author’s experience, the one-per-mil tumescent solution failed once to create a clear operative field in the case of an extreme burn contracture in a prolonged healing state with inadequate epithelial coverage and excessive vascularity. No complication related to this technique has been observed. Surgical outcomes were also good. The use of this technique in flap procedures has also been encouraging. However, one must exercise caution when using this technique on perforator flaps. Syringe needle penetration may injure the perforator vessels and compromise the flap’s vitality, as previously reported.2 In summary, the one-per-mil tumescent solution is effective in creating a clear operative field in hand surgery. The solution confirms the practice of nontourniquet hand surgery, and is even safer than the previous practice of higher epinephrine concentration. It also potentially bears the safest epinephrine concentration for hand and upper extremity surgery. DISCLOSURE The authors have no commercial association or financial disclosure that might pose or create a conflict of interest with information presented in this article. Theddeus O. H. Prasetyono, M.D. Division of Plastic Surgery Department of Surgery Cipto Mangunkusumo Hospital Faculty of Medicine University of Indonesia Jakarta, Indonesia Johannes A. Biben, M.D.